PERICARDIAL DISEASES

6TH YEAR CARDIOVASCULAR LECTURES

DR. RUOT GARJIEK TENY

MBBS, MMED(INT. MED), CERT. CARDIO.
 BACKGROUND
• The normal pericardium is a double layered sac.

• The visceral pericardium is a serous membrane

• The parietal pericardium is a fibrous membrane, separated from the serous

pericardium by a small fluid of 15-50 mls.

• The normal pericardium, exert a restrictive force that prevents sudden

dilatation of the chambers during exercise.

• It also reserves the anatomic position of the heart, and prevent spread of
infections from the adjacent organs or structures.
 ACUTE PERICARDITIS

• Is the most common pathologic process involving the pericardium

Etiology:
1. Infectious pericarditis:
a. Viral: (coxackie virus, mumps, adenoviruse, hepatitis and HIV)
b. Pyogenic (pneumococcus, Streptococcus, staph and Nisseria)
c. Tuberculosis: the commonest cause of pericarditis and pericardial
effusion in Africa
d. Others (Fungal, syphilis, protozoal infection and parasitic infection)
 CONT..

2. Noninfectiuos pericarditis:
a. Acute myocardia infarction
b. Uremia
c. Neoplasia
d. Tumor metastasis to pericardium (lung, breast cancer, lymphoma and
leukemia)
e. Myxedema
f. Trauma
g. Postirradiation
h. Sarcoidosis
 CONT..

3. Pericarditis related to autoimmunity:

a. Rheumatic fever
b. SLE, RA, Ankylosing spondylitis, scleroderma
c. Drugs induced (Hydralazine, procainamide, phenytoin, isonizide and
anticoagulant).
d. Postcardiac injury (post MI, postpericadiotomy)
 CLINICAL CLASSIFICATION

Acute pericarditis: (< 6 weeks)

a. Fibrinous
b. Effusive (serous or sanguineous)
Subacute pericarditis: (6 weeks to 6 months)
c. Effusive – constrictive
d. Constrictive
Chronic pericarditis: (> 6 months)
e. Constrictive b. Adhesive (nonconstrictive)
c. Effusive
 CLINICAL PRESENTATION

1. Chest pain: pleuritic retrosternal chest pain. Relieve by sitting up

and leaning forward and worsened by lying flat
2. Features of heart failure: (dysponea, Legs swelling, cough and
abdominal distention.
3. Symptoms related to the underlying etiology
 CLINICAL EXAMINATION

• Distended neck veins

• Difficulty locating apex beat
• Muffle heart sound
• Pericardial friction rub
• Eward’s sign (dullness and increased fremitus beneath the angle of left
scapula)
 INVESTIGATIONS

ECG: ST segment elevation, electrical alternans and small voltage QRS

complexes.
Echocardiogram: Very sensitive, non-invasive and can help in
diagnosing pericardial effusion and tamponade.
CT scan and cardiac MRI: can confirm the presence of pericardial
thickening, and effusion.
Investigations directed to specific etiology: (TSH, sputum AFB, ANA,
RF, anti CCP etc…)
Pericardial fluid analysis
 TREATMENT OF ACUTE PERICARDITIS

• No specific treatment for acute pericarditis

• Anti-inflamatory agents can be used;
a. Ibuprofen 400- 600 mg TDS/ 2 weeks
b. Indomethacine 50 mg po TDS/ 2 weeks
c. Colchicine 0.5mg BD/ 4-8 weeks
d. Prednisone 1 mg/ kg per day for 3-5 days then tapered.
• Anticoagulation should be avoided
• Pericardiectomy can be indicated in those with recurrent effusion not
responsive to NSAIDS and steroids.
 CARDIAC TAMPONADE

Definition: Accumulation of fluid in pericardial space in large

quantities that causes the obstruction of the inflow of the ventricles.

• This may be fatal if not recognized and treated promptly.

• The most common cause in Africa in TB pericardiatis
• Other causes are idiopathic pericarditis, uremic pericarditis and
neoplastic.
 CLINICAL PRESENTATION

Beck’s triad: hypotension, soft or absent heart sounds and jugular

venous distension
• Dyspnoea
• Orthopnea
• Hepatic engorgement
Paradoxical pulse:
• Important clue to the presence of tamponade
• Consist of greater than 10 mmHg inspiratory decline in systolic
arterial pressure.
 DIAGNOSIS

• Echocardiogram; is the single most important diagnostic tool in

cardiac tamponade
• CT scan, Transesophageal echo are important in diagnosing loculated
pericardial effusion
 TREATMENT OF CARDIAC TAMPONADE

• Patient with acute pericarditis should be observed for development of an

effusion.

• Patients with large effusion should undergo pericardiocentesis or watch

closely for sign of cardiac tamponade

• Patient with tamponade should have urgent pericardiocentesis under

ultrasound guided using apical, parasternal or subxyphoid approach.

• Pericardial fluid should be analyze for chemistry, MCS and cytology

 CHRONIC CONSTRICTIVE PERICARDITIS

• Occurs as a result of obliteration of pericardial cavity with a formation

of granulation tissue.
• This results in inability of the ventricles to fill because of the
limitations from the rigid, thickened pericardium.
• Ventricular filling is unimpeded during early diastole, but reduced
abruptly when elastic limit of pericardium is reached.
• Ventricular end diastolic and stroke volumes are reduced and the ED
pressure is elevated in both atria and ventricles.
• Systolic function may be normal or only mildly reduced.
 CLINICAL AND LABORATORY FINDINGS

• Weakness
• Fatigue
• Abdominal distension
• Edema
• Exertional dyspnea and orthopnea
• Distended neck veins
• Distant heart sounds and pericardial knock
 CONT..

ECG: low voltage QRS, diffuse T wave inversion and atrial fibrillation.
CXR: slight cardiomegaly and pericardial calcification.
Echocardiogram: Shows pericardial thickening, dilatation of inferior
vena cava and hepatic veins and a sharp halt in ventricular filling and
normal LV function.
 TREATMENT

• Dietary sodium restriction

• Diuretics are useful in pre and post operative preparation
• Pericardial resection is the only definitive treatment of constrictive
pericarditis.
• The operative mortality risk is about 5 – 10% even in experienced
centers
THANK YOU